Did the physician insert a pacemaker or pacing cardioverter-defibrillator (ICD)? Did the pacemaker or ICD system include single, double, or multiple leads? What, specifically, did the physician remove? Did he or she replace it, too? These are just a few of the questions that come to mind when billing for these procedures.
Relative value units (RVU) can vary significantly, depending on the code reported. (Note: To view specific RVUs for each code, visit the CMS site and unzip the file ‘RVU12AR.’). Physicians must ensure that documentation reflects the actual work they performed in order to receive accurate reimbursement.
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education at the AAPC in Salt Lake City, provided an overview of new codes and CPT® guidelines for 2012 related to pacemakers and ICDs as well as what physicians and coders should keep in mind.
Although most physicians distinguish in their operative reports between pacemakers and ICDs, new CPT guidelines provide an explicit definition for pacemakers and ICDs. Both pacemakers and ICDs include a pulse generator and one or more electrodes. With a pacemaker, however, only one electrode is inserted into either the atrium or the ventricle (for a single-chamber pacemaker system) or into the right atrium and right ventricle (for a dual-chamber pacemaker). Alternatively, an ICD may require multiple leads even when only a single chamber is being paced. This isn’t new information per se, but it does help coders understand the differences between the two devices.
One noteworthy new guideline pertains to the removal of a pacemaker or ICD. When a physician removes either of these devices without replacing them, coders should report either 33233 or 33241.
However, physicians may also remove and replace only a certain part of a pacemaker or ICD (i.e., the pulse generator the lead[s]). New combination codes 33227-33229 and 33262-33264, for example, denote both the removal of a pacemaker or ICD and the replacement of a new pulse generator only. Previously, coders would have reported two separate codes—one for the removal and one for the replacement. Other new CPT guidelines in this section provide explicit direction regarding how to bill for the insertion, removal, replacement, repositioning, and upgrade of these devices.
CPT guidelines include a helpful table
Coders will be happy to know that CPT guidelines now include a helpful table that simplifies the process for reporting transvenous procedures related to pacemakers and ICDs. The table provides a quick-reference guide for procedures and helps coders quickly choose the appropriate code to ensure accurate reimbursement.
Another important new guideline pertains to imaging (i.e., radiological supervision and interpretation), which is now included in codes 33206-33249 when it’s related to the pacemaker or ICD procedure. This means that physicians can no longer bill separately for it. However, per the new guidelines, if physicians use fluoroscopic guidance to perform the procedures, they may bill separately for it using code 76000.
Note that many of the codes in this section—including new ones for 2012—include moderate (conscious) sedation, which means coders cannot report this service separately. Appendix G of the CPT Manual includes a summary of CPT codes that include moderate sedation. These codes are also denoted by a bulls-eye symbol in the surgical section of the manual.
Coders should also note the various parenthetical notes provided throughout this section, many of which indicate that certain codes should not be reported together. Inaccurate billing (e.g., reporting the removal and replacement of a pulse generator separately or inappropriately unbundling imaging services) not only leads to inaccurate reimbursement, but it can also result in line-item denials that could—over time—raise a payer’s red flag and prompt an audit.
Multiple codes may be needed for complete payment
In some cases, however, coders need to report multiple codes to ensure that physicians are paid completely. For example, when a physician removes the entire pacemaker or ICD system and replaces both the leads and pulse generator, report 33233 in conjunction with either 33234 or 33235 and 33206-33208. Therefore, three separate codes are required for this procedure.
Physicians should note that reimbursement differs depending on whether a procedure involves a single vs. dual vs. multiple lead system. New codes for 2012 (i.e., 33221, 33229, 33231, and 33264) actually specify multiple leads whereas this information was previously captured using add-on code 33225. In addition, new CPT guidelines clearly define each type of lead system, and physician documentation should reflect this information to ensure accurate reimbursement.